This R-21 project explores whether time spent by primary care physicians (PCPs) both in face-to-face office visits and out-of-office efforts may substitute for (a) services they directly order, such as tests, imaging, and referrals to specialists, and/or (b) services their patients may access directly from other PCPs, specialists, and urgent care settings. Current fee schedules reward PCPs relatively poorly for the time they spend in face- to-face visits, but rarely for out-of-office "touches" such as phone calls and e-messaging recorded in the patient's chart, and not at all for other time and effort that reduce the use of other costly services. "Bending the cost curve" will require less resource use, not just lower prices for resources. Lowering expenditures, however, is politically unacceptable if it reduces quality. We examine both clinical quality indicators and patient assessments of their care to see if they are comparable between PCPs whose patients consume many resources relative to those consuming fewer resources. Data will be drawn from the Palo Alto Medical Foundation (PAMF), a large multispecialty group practice with nearly 1000 physicians in 46 sites. PAMF approximates a microcosm of the US healthcare system in important ways-its physicians are paid on a FFS basis, there is a wide variety of insurance type and coverage, no fixed formulary, and physicians have substantial flexibility in their practice. PAMF's data systems, however, facilitate complete capture of all clinical activities, detailed risk adjustment, measurement of PCP time in the office and using the electronic health records out of the office, and routine reporting of quality metrics and patient assessments. This allows for the rapid completion of the project. Speed is important because providers will be forming and implementing Accountable Care Organizations (ACOs) by 2012. ACOs are predicated on changing physician behavior to encourage less costly approaches to care. Little is known, however, about how to compensate physicians within ACOs to reward more efficient use of resources yet maintain or improve quality of care. Our empirical findings will inform the design of modifications to fee schedules that can be adopted by ACOs. PAMF is examining how to structure itself as an ACO so its leadership will assess the feasibility of our proposals, providing a "reality test" of our recommendations before they are widely disseminated. PUBLIC HEALTH RELEVANCE: This project explores whether increased time spent by primary care physicians (PCPs) may substitute for (a) services they directly order, such as tests, imaging, and referrals to specialists, and/or (b) services their patients may access directly from other PCPs, specialists, and urgent care sites. We examine clinical quality indicators and patient assessments across low- and high-cost PCPs. This project will inform the Accountable Care Organization concept of encouraging less costly approaches to care.